Although croup accounts for the large majority of cases of acute upper airways obstruction, several other uncommon conditions need to be considered in the differential diagnosis. Diphtheria is seen only in children who have not been immunised against the disease. Always ask about immunisations in any child with fever and the signs of upper airways obstruction, particularly if they have been to endemic areas recently.
Marked tonsillar swelling in infectious mononucleosis or acute tonsillitis can rarely compromise the upper airway. The passage of a nasopharyngeal tube may give instant relief. Retropharyngeal abscess is uncommon nowadays, but can present with fever and the features of upper airway obstruction together with feeding difficulties. Treatment is by surgical drainage and intravenous antibiotics.
Anaphylaxis is a potentially life-threatening immunologically mediated syndrome in which laryngeal oedema can develop over minutes often with swelling (angioneurotic oedema) of the face, mouth and tongue. Food allergies, especially nuts and drug reactions, especially contrast media and anaesthetic drugs are usual causes of this.
Prodromal symptoms of flushing, itching, facial swelling and urticaria usually precede stridor. Abdominal pain, diarrhoea, wheeze and shock may be additional or alternative manifestations of anaphylaxis (page 108).
A severe episode of anaphylaxis can be predicted in patients with a previous severe episode or a history of increasingly severe reaction, a history of asthma or treatment with beta blockers.
The inquisitive and fearless toddler and the infant with toddler siblings is at risk of inhaling a foreign body. If an inhaled foreign body lodges in the larynx or trachea, the outcome is often fatal at home, unless measures such as those discussed in Chapter 4 are performed. Should a child present to hospital, especially during waking hours, with very sudden onset of stridor and other signs of acute upper airway obstruction, and particularly if there is no fever or preceding illness, then a laryngeal foreign body is the likely diagnosis. A history of eating or of playing with small objects immediately prior to the onset of symptoms is strong supportive evidence. Foodstuffs (nuts, sweets, meat) are the commonest offending items. In 1998 16 children in England and Wales died from choking. In all but one food was the cause of obstruction. In some instances, objects may compress the trachea from their position of lodgement in the upper oesophagus producing a similar but less severe picture of airway obstruction.
The object may pass through the larynx into the bronchial tree, where it produces a persistent cough of very acute onset, and unilateral wheezing. Examination of the chest may reveal decreased air entry on one side or evidence of a collapsed lung. Inspiratory and expiratory chest radiographs may show mediastinal shift on expiration due to gas-trapping distal to the bronchial foreign body. Removal through a bronchoscope under general anaesthetic should be performed as soon as possible as there is a risk of coughing moving the object into the trachea and causing life-threatening obstruction.
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